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GI System Lecture 4

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GI System Lecture 4

  1. 1. Learning Objectives:At the end of this lecture, you will be able to:1. Identify the health care teaching needs of patientswith constipation or diarrhea.2. Compare the conditions of malabsorption with regardto their pathophysiology, clinical manifestations, andmanagement.JOFRED M. MARTINEZ, RN
  2. 2. 3. Use the nursing process as a framework for care ofpatients with diverticulitis.4. Compare regional enteritis and ulcerative colitis withregard to their pathophysiology, clinicalmanifestations, diagnostic evaluation, and medical,surgical, and nursing management.5. Use the nursing process as a framework for care ofthe patient with an inflammatory bowel disease.6. Describe the responsibilities of the nurse in meetingthe needs of the patient with an ileostomy.7. Describe the various types of intestinal obstructionsand their management.Learning Objectives (Cont’d.):
  3. 3. 8. Use the nursing process as a framework for care ofthe patient with cancer of the colon or rectum.9. Use the nursing process as a framework for care ofthe patient with an anorectal condition.Learning Objectives (Cont’d.):
  4. 4. CONSTIPATION• Constipation is a term used to describe an abnormalinfrequency or irregularity of defecation, abnormalhardening of stools that makes their passage difficultand sometimes painful, a decrease in stool volume, orretention of stool in the rectum for a prolonged period.• Constipation can be caused by certain medications (ie,tranquilizers, anticholinergics, antidepressants,antihypertensives, opioids, antacids with aluminum,and iron); rectal or anal disorders (eg, hemorrhoids,fissures); obstruction (eg, cancer of the bowel);Abnormalities in Fecal Elimination
  5. 5. CONSTIPATION• metabolic, neurologic, and neuromuscular conditions(eg, diabetes mellitus, Hirschsprung’s disease,Parkinson’s disease, multiple sclerosis); endocrinedisorders (eg, hypothyroidism, pheochromocytoma);lead poisoning; and connective tissue disorders (eg,scleroderma, lupus erythematosus).Abnormalities in Fecal Elimination
  6. 6. CLINICAL MANIFESTATIONS• Clinical manifestations include abdominal distention,borborygmus, pain and pressure, decreased appetite,headache, fatigue, indigestion, a sensation ofincomplete emptying, straining at stool, and theelimination of small-volume, hard, dry stools.Abnormalities in Fecal Elimination
  7. 7. ASSESSMENT AND DIAGNOSTIC FINDINGS• The diagnosis of constipation is based on results of thepatient’s history, physical examination, possibly abarium enema or sigmoidoscopy, and stool testing foroccult blood.• Anorectal manometry (ie, pressure studies) may beperformed to determine malfunction of the muscle andsphincter.• Defecography and bowel transit studies can also assistin the diagnosis.Abnormalities in Fecal Elimination
  8. 8. COMPLICATIONSComplications of constipation include:• hypertension• fecal impaction• hemorrhoids and fissures• megacolonAbnormalities in Fecal Elimination
  9. 9. MEDICAL MANAGEMENT• Treatment is aimed at the underlying cause ofconstipation and includes education, bowel habittraining, increased fiber and fluid intake, and judicioususe of laxatives.• Management may also include discontinuing laxativeabuse.• Routine exercise to strengthen abdominal muscles isencouraged.• Biofeedback is a technique that can be used to helppatients learn to relax the sphincter mechanism toexpel stool.Abnormalities in Fecal Elimination
  10. 10. MEDICAL MANAGEMENT• Daily addition to the diet of 6 to 12 teaspoonfuls ofunprocessed bran is recommended, especially for thetreatment of constipation in the elderly.• If laxative use is necessary, one of the following may beprescribed: bulk-forming agents, saline and osmoticagents, lubricants, stimulants, or fecal softeners.Abnormalities in Fecal Elimination
  11. 11. NURSING MANAGEMENT• The nurse elicits information about the onset andduration of constipation, current and past eliminationpatterns, the patient’s expectation of normal bowelelimination, and lifestyle information during the healthhistory interview.• Past medical and surgical history, current medications,and laxative and enema use are important, as isinformation about the sensation of rectal pressure orfullness, abdominal pain, excessive straining atdefecation, and flatulence.• Patient education and health promotion are importantfunctions of the nurse.Abnormalities in Fecal Elimination
  12. 12. NURSING MANAGEMENT• After the health history is obtained, the nurse setsspecific goals for teaching. Goals for the patient includerestoring or maintaining a regular pattern of elimination,ensuring adequate intake of fluids and high-fiber foods,learning about methods to avoid constipation, relievinganxiety about bowel elimination patterns, and avoidingcomplications.Abnormalities in Fecal Elimination
  13. 13. DIARRHEA• Diarrhea is increased frequency of bowel movements(more than three per day), increased amount of stool(more than 200 g per day), and altered consistency (ie,looseness) of stool.• It is usually associated with urgency, perianaldiscomfort, incontinence, or a combination of thesefactors.• Any condition that causes increased intestinalsecretions, decreased mucosal absorption, or alteredmotility can produce diarrhea.Abnormalities in Fecal Elimination
  14. 14. DIARRHEA• Diarrhea can be caused by certain medications (eg,thyroid hormone replacement, stool softeners andlaxatives, antibiotics, chemotherapy, antacids), certaintube feeding formulas, metabolic and endocrinedisorders (eg, diabetes, Addison’s disease,thyrotoxicosis), and viral or bacterial infectiousprocesses (eg, dysentery, shigellosis, food poisoning).• Other disease processes associated with diarrhea arenutritional and malabsorptive disorders (eg, celiacdisease), anal sphincter defect, Zollinger-Ellisonsyndrome, paralytic ileus, intestinal obstruction, andacquired immunodeficiency syndrome (AIDS).Abnormalities in Fecal Elimination
  15. 15. CLINICAL MANIFESTATIONS• In addition to the increased frequency and fluid contentof stools, the patient usually has abdominal cramps,distention, intestinal rumbling, anorexia, and thirst.• Painful spasmodic may occur with defecation.• Other symptoms depend on the cause and severity ofthe diarrhea but are related to dehydration and to fluidand electrolyte imbalances.Abnormalities in Fecal Elimination
  16. 16. ASSESSMENT AND DIAGNOSTIC FINDINGS• When the cause of the diarrhea is not obvious, thefollowing diagnostic tests may be performed: completeblood cell count, chemical profile, urinalysis, routinestool examination, and stool examinations for infectiousor parasitic organisms, bacterial toxins, blood, fat, andelectrolytes.• Endoscopy or barium enema may assist in identifyingthe cause.Abnormalities in Fecal Elimination
  17. 17. COMPLICATIONS• Complications of diarrhea include the potential forcardiac dysrhythmias because of significant fluid andelectrolyte.• Decreased potassium levels cause cardiacdysrhythmias (ie, atrial and ventricular tachycardia,ventricular fibrillation, and premature ventricularcontractions) that can lead to death.Abnormalities in Fecal Elimination
  18. 18. MEDICAL MANAGEMENT• Primary management is directed at controllingsymptoms, preventing complications, and eliminating ortreating the underlying disease.• Certain medications (eg, antibiotics, anti-inflammatoryagents) may reduce the severity of the diarrhea andtreat the underlying disease.Abnormalities in Fecal Elimination
  19. 19. NURSING MANAGEMENT• The nurse’s role includes assessing and monitoring thecharacteristics and pattern of diarrhea.• A health history addresses the patient’s medicationtherapy, medical and surgical history, and dietarypatterns and intake.• Assessment includes abdominal auscultation andpalpation for abdominal tenderness. Inspection of theabdomen and mucous membranes and skin isimportant to determine hydration status.• Stool samples are obtained for testing.Abnormalities in Fecal Elimination
  20. 20. NURSING MANAGEMENT• During an episode of acute diarrhea, the nurseencourages bed rest and intake of liquids and foodslow in bulk until the acute attack subsides.• When food intake is tolerated, the nurse recommends abland diet of semisolid and solid foods.• The patient should avoid caffeine, carbonatedbeverages, and very hot and very cold foods.• It may be necessary to restrict milk products, fat,whole-grain products, fresh fruits, and vegetables forseveral days.Abnormalities in Fecal Elimination
  21. 21. NURSING MANAGEMENT• The nurse administers antidiarrheal medications suchas diphenoxylate (Lomotil) and loperamide (Imodium)as prescribed.• Intravenous fluid therapy may be necessary for rapidrehydration, especially for the elderly and those withpreexisting GI conditions (eg, IBD).• It is important to closely monitor serum electrolytelevels.Abnormalities in Fecal Elimination
  22. 22. FECAL INCONTINENCE• The term fecal incontinence describes the involuntarypassage of stool from the rectum.• Several factors influence fecal continence the amountand consistency of stool, the integrity of the analsphincters and musculature, and rectal motility.CLINICAL MANIFESTATIONS• Patients may have minor soiling, occasional urgencyand loss of control, or complete incontinence.• Patients may also experience poor control of flatus,diarrhea, or constipation.Abnormalities in Fecal Elimination
  23. 23. ASSESSMENT AND DIAGNOSTIC FINDINGS• A rectal examination and other endoscopicexaminations such as a flexible sigmoidoscopy areperformed to rule out tumors, inflammation, or fissures.• X-ray studies such as barium enema, computedtomography (CT) scans, anorectal manometry, andtransit studies may be helpful in identifying alterationsin intestinal mucosa and muscle tone or in detectingother structural or functional problems.Abnormalities in Fecal Elimination
  24. 24. MEDICAL MANAGEMENT• If fecal incontinence is related to diarrhea, theincontinence may disappear when diarrhea issuccessfully treated.• Fecal incontinence is frequently a symptom of a fecalimpaction. After the impaction is removed and therectum is cleansed, normal functioning of the anorectalarea can resume.• Biofeedback therapy can be of assistance if theproblem is decreased sensory awareness or sphinctercontrol.Abnormalities in Fecal Elimination
  25. 25. MEDICAL MANAGEMENT• Bowel training programs can also be effective.• Surgical procedures include surgical reconstruction,sphincter repair, or fecal diversion.Abnormalities in Fecal Elimination
  26. 26. NURSING MANAGEMENT• The nurse takes a thorough health history, includinginformation about previous surgical procedures, chronicillnesses, bowel habits and problems, and currentmedication regimen.• The nurse also completes an examination of the rectalarea.• The nurse initiates a bowel-training program thatinvolves setting a schedule to establish bowelregularity.• Use suppositories to stimulate the anal reflex.Abnormalities in Fecal Elimination
  27. 27. NURSING MANAGEMENT• Biofeedback can be used in conjunction with thesetherapies to help the patient improve sphinctercontractility and rectal sensitivity.• The nurse encourages and teaches meticulous skinhygiene.• Continence sometimes cannot be achieved, and thenurse assists the patient and family to accept and copewith this chronic situationAbnormalities in Fecal Elimination
  28. 28. IRRITABLE BOWEL SYNDROME• IBS is one of the most common GI problems.• It occurs more commonly in women than in men, andthe cause is still unknown.• Various factors are associated with the syndrome:heredity, psychological stress or conditions such asdepression and anxiety, a diet high in fat andstimulating or irritating foods, alcohol consumption, andsmoking.• The diagnosis is made only after tests have beencompleted that prove the absence of structural or otherdisorders.Abnormalities in Fecal Elimination
  29. 29. Abnormalities in Fecal Elimination
  30. 30. CLINICAL MANIFESTATIONS• The primary symptom is an alteration in bowelpatterns—constipation, diarrhea, or a combination ofboth. Pain, bloating, and abdominal distention oftenaccompany this change in bowel pattern.• The abdominal pain is sometimes precipitated byeating and is frequently relieved by defecation.Abnormalities in Fecal EliminationIBS is not an inflammatory condition, and anatomicabnormalities are not present. It does not lead toinflammatory bowel disease and is not a life-threatening disorder
  31. 31. ASSESSMENT AND DIAGNOSTIC FINDINGS• Stool studies, contrast x-ray studies, and proctoscopymay be performed to rule out other colon diseases.Barium enema and colonoscopy may reveal spasm,distention, or mucus accumulation in the intestine.• Manometry and electromyography are used to studyintraluminal pressure changes generated by spasticity.Abnormalities in Fecal Elimination
  32. 32. MEDICAL MANAGEMENT• The goals of treatment are aimed at relievingabdominal pain, controlling the diarrhea or constipation,and reducing stress.• Restriction and then gradual reintroduction of foodsthat are possibly irritating may help determine whattypes of food are acting as irritants (eg, beans,caffeinated products, fried foods, alcohol, spicy foods).• A healthy, high-fiber diet is prescribed to help controlthe diarrhea and constipation.• Exercise can assist in reducing anxiety and increasingintestinal motility.Abnormalities in Fecal Elimination
  33. 33. MEDICAL MANAGEMENT• Patients often find it helpful to participate in a stressreduction or behavior-modification program.• Hydrophilic colloids (ie, bulk) and antidiarrheal agents(eg, loperamide) may be given to control the diarrheaand fecal urgency.• Antidepressants can assist in treating underlyinganxiety and depression.• Anticholinergics and calcium channel blockersdecrease smooth muscle spasm, decreasing crampingand constipation.Abnormalities in Fecal Elimination
  34. 34. NURSING MANAGEMENT• The patient is encouraged to eat at regular times and tochew food slowly and thoroughly.• Although adequate fluid intake is necessary, fluidshould not be taken with meals because this results inabdominal distention.• Alcohol use and cigarette smoking are discouraged.Abnormalities in Fecal Elimination
  35. 35. CONDITIONS OF MALABSORPTION• Malabsorption is the inability of the digestive system toabsorb one or more of the major vitamins, minerals ,and nutrients.• Interruptions in the complex digestive process mayoccur anywhere in the digestive system and causedecreased absorption.• Diseases of the small intestine are the most commoncause of malabsorption.Conditions of Malabsorption
  36. 36. PATHOPHYSIOLOGY• Mucosal disorders causing generalized malabsorption (eg,celiac sprue, regional enteritis, radiation enteritis)• Infectious diseases causing generalized malabsorption (eg,small bowel bacterial overgrowth, tropical sprue, Whipple’sdisease)• Luminal problems causing malabsorption (eg, bile aciddeficiency, Zollinger-Ellison syndrome, pancreaticinsufficiency)• Postoperative malabsorption (eg, after gastric or intestinalresection)• Disorders that cause malabsorption of specific nutrients (eg,disaccharidase deficiency leading to lactose intolerance)Conditions of Malabsorption
  37. 37. CLINICAL MANIFESTATIONS• The hallmarks of malabsorption syndrome from anycause are diarrhea or frequent, loose, bulky, foul-smelling stools that have increased fat content and areoften grayish.• Patients often have associated abdominal distention,pain, increased flatus, weakness, weight loss, and adecreased sense of well-being.• The chief result of malabsorption is malnutrition,manifested by weight loss and other signs of vitaminand mineral deficiency.• Failure to absorb the fat-soluble vitamins A, D, and Kcauses a corresponding avitaminosis.Conditions of Malabsorption
  38. 38. ASSESSMENT AND DIAGNOSTIC FINDINGS• Stool studies for quantitative and qualitative fatanalysis, lactose tolerance tests, D-xylose absorptiontests, and Schilling tests.• The hydrogen breath test that is used to evaluatecarbohydrate absorption is performed if carbohydratemalabsorption is suspected.• Endoscopy with biopsy of the mucosa is the bestdiagnostic tool.• Biopsy of the small intestine is performed to assayenzyme activity or to identify infection or destruction ofmucosa.Conditions of Malabsorption
  39. 39. ASSESSMENT AND DIAGNOSTIC FINDINGS• Ultrasound studies, CT scans, and x-ray findings canreveal pancreatic or intestinal tumors that may be thecause.• A complete blood cell count is used to detect anemia.Pancreatic function tests can assist in the diagnosis ofspecific disorders.Conditions of Malabsorption
  40. 40. MEDICAL MANAGEMENT• Intervention is aimed at avoiding dietary substancesthat aggravate malabsorption and at supplementingnutrients that have been lost.• Common supplements are water-soluble vitamins, fat-soluble vitamins, and minerals.• Parenteral fluids may be necessary to treatdehydration.Conditions of Malabsorption
  41. 41. NURSING MANAGEMENT• The nurse provides patient and family educationregarding diet and the use of nutritional supplements.• It is important to monitor patients with diarrhea for fluidand electrolyte• imbalances.• The nurse conducts ongoing assessments to determineif the clinical manifestations related to the nutritionaldeficits have abated.• Patient education includes information about the risk ofosteoporosis related to malabsorption of calcium.Conditions of Malabsorption
  42. 42. APPENDICITIS• Appendicitis is an acute inflammation of the appendix.• It is the most common reason for emergencyabdominal surgery.• About 7% of the population will have appendicitis atsome time in their lives; males are affected more thanfemales, and teenagers more than adults.• It occurs most frequently between the ages of 10 and30 yearsAcute Inflammatory Intestinal DisordersPain that increases with movement and is relievedby flexion of the knees may indicate rupture of theappendix.
  43. 43. Acute Inflammatory Intestinal Disorders
  44. 44. Acute Inflammatory Intestinal Disorders
  45. 45. CLINICAL MANIFESTATIONS• Vague epigastric or periumbilical pain progresses toright lower quadrant pain and is usually accompaniedby a low-grade fever and nausea and sometimes byvomiting. Loss of appetite is common.• Local tenderness is elicited at McBurney’s point whenpressure is applied.• Rebound tenderness may be present.• Rovsing’s sign may be elicited by palpating the leftlower quadrant; this paradoxically causes pain to be feltin the right lower quadrant.Acute Inflammatory Intestinal Disorders
  46. 46. CLINICAL MANIFESTATIONS• If the appendix has ruptured, the pain becomes morediffuse; abdominal distention develops as a result ofparalytic ileus, and the patient’s condition worsens.• Constipation can also occur with an acute processsuch as appendicitis.Acute Inflammatory Intestinal DisordersAvoid using heat for pain management, becauseheat will increase blood flow to the appendix andincrease inflammation.If perforation is suspected, elevate the HOB to keepbowel contents down in one area; client will begoing to surgery shortly.
  47. 47. ASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is based on results of a complete physicalexamination and on laboratory and x-ray findings.• The complete blood cell count demonstrates anelevated white blood cell count.• The leukocyte count may exceed 10,000 cells/mm3,and the neutrophil count may exceed 75%.• Abdominal x-ray films, ultrasound studies, and CTscans may reveal a right lower quadrant density orlocalized distention of the bowel.Acute Inflammatory Intestinal Disorders
  48. 48. COMPLICATIONS• The major complication of appendicitis is perforation ofthe appendix which can lead to peritonitis or anabscess.• The incidence of perforation is 10% to 32%.• The incidence is higher in young children and theelderly. Perforation generally occurs 24 hours after theonset of pain.• Symptoms include a fever of 37.7°C or higher, a toxicappearance, and continued abdominal pain ortenderness.Acute Inflammatory Intestinal Disorders
  49. 49. MEDICAL MANAGEMENT• Surgery is indicated if appendicitis is diagnosed.• To correct or prevent fluid and electrolyte imbalanceand dehydration, antibiotics and intravenous fluids areadministered until surgery is performed.• Analgesics can be administered after the diagnosis ismade.• Appendectomy is performed as soon as possible todecrease the risk of perforation.Acute Inflammatory Intestinal Disorders
  50. 50. NURSING MANAGEMENT• Goals include relieving pain, preventing fluid volumedeficit, reducing anxiety, eliminating infection from thepotential or actual disruption of the GI tract, maintainingskin integrity, and attaining optimal nutrition.• The nurse prepares the patient for surgery, whichincludes an intravenous infusion to replace fluid lossand promote adequate renal function and antibiotictherapy to prevent infection.• If there is evidence or likelihood of paralytic ileus, anasogastric tube is inserted.Acute Inflammatory Intestinal Disorders
  51. 51. NURSING MANAGEMENT• After surgery, the nurse places the patient in a semi-Fowler position.• An opioid, usually morphine sulfate, is prescribed torelieve pain.• When tolerated, oral fluids are administered.Acute Inflammatory Intestinal Disorders
  52. 52. DIVERTICULAR DISEASE• A diverticulum is a saclike outpouching of the lining ofthe bowel that extends through a defect in the musclelayer.• Diverticulosis exists when multiple diverticula arepresent without inflammation or symptoms.• Diverticulitis results when food and bacteria retainedin a diverticulum produce infection and inflammationthat can impede drainage and lead to perforation orabscess formation.Acute Inflammatory Intestinal Disorders
  53. 53. Acute Inflammatory Intestinal Disorders
  54. 54. Acute Inflammatory Intestinal Disorders
  55. 55. Acute Inflammatory Intestinal Disorders
  56. 56. Acute Inflammatory Intestinal Disorders
  57. 57. CLINICAL MANIFESTATIONS• Signs of acute diverticulosis are bowel irregularity andintervals of diarrhea, abrupt onset of crampy pain in theleft lower quadrant of the abdomen, and a low-gradefever.• The patient may have nausea and anorexia, and somebloating or abdominal distention may occur.• With repeated local inflammation of the diverticula, thelarge bowel may narrow with fibrotic strictures, leadingto cramps, narrow stools, and increased constipation.• Weakness, fatigue, and anorexia are commonsymptoms.Acute Inflammatory Intestinal Disorders
  58. 58. CLINICAL MANIFESTATIONS• With acute diverticulosis, the patient reports mild tosevere pain in the lower left quadrant.• The condition, if untreated, can lead to septicemia.Acute Inflammatory Intestinal Disorders
  59. 59. ASSESSMENT AND DIAGNOSTIC FINDINGS• A CT scan is the procedure of choice and can revealabscesses.• Abdominal x-ray findings may demonstrate free airunder the diaphragm if a perforation has occurred fromthe diverticulitis.• Diverticulosis may be diagnosed using barium enema,which shows narrowing of the colon and thickenedmuscle layers.• A colonoscopy may be performed if there is no acutediverticulitis or after resolution of an acute episode tovisualize the colon, determine the extent of thedisease, and rule out other conditions.Acute Inflammatory Intestinal Disorders
  60. 60. ASSESSMENT AND DIAGNOSTIC FINDINGS• Laboratory tests that assist in diagnosis include acomplete blood cell count, revealing an elevatedleukocyte count, and elevated sedimentation rate.Acute Inflammatory Intestinal Disorders
  61. 61. COMPLICATIONS• Complications of diverticulitis include peritonitis,abscess formation, and bleeding.• An inflamed diverticulum that perforates results inabdominal pain localized over the involved segment,usually the sigmoid; local abscess or peritonitis follows.• Abdominal pain, a rigid boardlike abdomen, loss ofbowel sounds, and signs and symptoms of shock occurwith peritonitis.• Noninflamed or slightly inflamed diverticula may erodeareas adjacent to arterial branches, causing massiverectal bleeding.Acute Inflammatory Intestinal Disorders
  62. 62. MEDICAL MANAGEMENTDIETARY AND MEDICATION MANAGEMENT• When symptoms occur, rest, analgesics, andantispasmodics are recommended.• Initially, the diet is clear liquid until the inflammationsubsides; then, a high-fiber, low-fat diet isrecommended. Antibiotics are prescribed for 7 to 10days.• A bulkforming laxative also is prescribed.• Withholding oral intake, administering intravenousfluids, and instituting nasogastric suctioning if vomitingor distention occurs rests the bowel.Acute Inflammatory Intestinal Disorders
  63. 63. MEDICAL MANAGEMENTDIETARY AND MEDICATION MANAGEMENT• Broad-spectrum antibiotics are prescribed for 7 to 10days.• An opioid is prescribed for pain relief; morphine is notused because it increases segmentation andintraluminal pressures.• Oral intake is increased as symptoms subside.• A low-fiber diet may be necessary until signs ofinfection decrease.• Antispasmodics such as propantheline bromide (Pro-Banthine) and oxyphencyclimine (Daricon) may beprescribed.Acute Inflammatory Intestinal Disorders
  64. 64. MEDICAL MANAGEMENTDIETARY AND MEDICATION MANAGEMENT• Normal stools can be achieved by using bulkpreparations (Metamucil) or stool softeners (Colace),by instilling warm oil into the rectum, or by inserting anevacuant suppository (Dulcolax).Acute Inflammatory Intestinal Disorders
  65. 65. SURGICAL MANAGEMENT• Although acute diverticulitis usually subsides withmedical management, immediate surgical interventionis necessary if complications (eg, perforation,peritonitis, abscess formation, hemorrhage,obstruction) occur.Two types of surgery are considered:• One-stage resection in which the inflamed area isremoved and a primary end-to-end anastomosis iscompleted• Multiple-staged procedures for complications such asobstruction or perforationAcute Inflammatory Intestinal Disorders
  66. 66. Acute Inflammatory Intestinal Disorders
  67. 67. PERITONITIS• Peritonitis is inflammation of the peritoneum, theserous membrane lining the abdominal cavity andcovering the viscera.• Usually, it is a result of bacterial infection; theorganisms come from diseases of the GI tract or, inwomen, from the internal reproductive organs.• Peritonitis can also result from external sources suchas injury or trauma or an inflammation that extendsfrom an organ outside the peritoneal area, such as thekidney.Acute Inflammatory Intestinal Disorders
  68. 68. PERITONITIS• The most common bacteria implicated are Escherichiacoli, Klebsiella, Proteus, and Pseudomonas. Inflammationand paralytic ileus are the direct effects of the infection.• Other common causes of peritonitis are appendicitis,perforated ulcer, diverticulitis, and bowel perforation.• Peritonitis may also be associated with abdominalsurgical procedures and peritoneal dialysis.Acute Inflammatory Intestinal DisordersPain over the entire abdominal area with reboundtenderness (pain after the abdomen is pressed andreleased suddenly) may indicate peritonitis.
  69. 69. Acute Inflammatory Intestinal Disorders
  70. 70. CLINICAL MANIFESTATIONS• The early clinical manifestations of peritonitis frequentlyare the symptoms of the disorder causing the condition.At first, a diffuse type of pain is felt. The pain tends tobecome constant, localized, and more intense near thesite of the inflammation.• The affected area of the abdomen becomes extremelytender and distended, and the muscles become rigid.Rebound tenderness and paralytic ileus may be present.• Usually, nausea and vomiting occur and peristalsis isdiminished.• The temperature and pulse rate increase, and there isalmost always an elevation of the leukocyte count.Acute Inflammatory Intestinal Disorders
  71. 71. ASSESSMENT AND DIAGNOSTIC FINDINGS• The leukocyte count is elevated.• The hemoglobin and hematocrit levels may be low ifblood loss has occurred.• Serum electrolyte studies may reveal altered levels ofpotassium, sodium, and chloride.• An abdominal x-ray is obtained, and findings may showair and fluid levels as well as distended bowel loops.• A CT scan of the abdomen may show abscessformation. Peritoneal aspiration and culture andsensitivity studies of the aspirated fluid may revealinfection and identify the causative organisms.Acute Inflammatory Intestinal Disorders
  72. 72. COMPLICATIONS• Frequently, the inflammation is not localized and thewhole abdominal cavity becomes involved in ageneralized sepsis.• Shock may result from septicemia or hypovolemia.• The inflammatory process may cause intestinalobstruction, primarily from the development of boweladhesions.• The two most common postoperative complications arewound evisceration and abscess formation.Acute Inflammatory Intestinal Disorders
  73. 73. MEDICAL MANAGEMENT• Fluid, colloid, and electrolyte replacement is the majorfocus of medical management.• Analgesics are prescribed for pain.• Antiemetics are administered as prescribed for nauseaand vomiting.• Intestinal intubation and suction assist in relievingabdominal distention and in promoting intestinalfunction.• Oxygen therapy by nasal cannula or mask can promoteadequate oxygenation.Acute Inflammatory Intestinal Disorders
  74. 74. MEDICAL MANAGEMENT• Massive antibiotic therapy is usually initiated early in thetreatment of peritonitis.• Surgical objectives include removing the infectedmaterial and correcting the cause. Surgical treatment isdirected toward excision (ie, appendix), resection with orwithout anastomosis (ie, intestine), repair (ie,perforation), and drainage (ie, abscess).• With extensive sepsis, a fecal diversion may need to becreated.Acute Inflammatory Intestinal Disorders
  75. 75. NURSING MANAGEMENT• Ongoing assessment of pain, vital signs, GI function,and fluid and electrolyte balance is important.• The nurse reports the nature of the pain, its location inthe abdomen, and any shifts in location.• Administering analgesic medication and positioning thepatient for comfort are helpful in decreasing pain.• Accurate recording of all intake and output and centralvenous pressure assists in calculating fluid replacement.The nurse administers and monitors closely intravenousfluids.Acute Inflammatory Intestinal Disorders
  76. 76. NURSING MANAGEMENT• The nurse increases fluid and food intake gradually andreduces parenteral fluids as prescribed.• Drains are frequently inserted during the surgicalprocedure, and the nurse must observe and record thecharacter of the drainage postoperatively.• Care must be taken when moving and turning thepatient to prevent the drains from being dislodged.Acute Inflammatory Intestinal Disorders
  77. 77. REGIONAL ENTERITIS (CROHN’S DISEASE)• Regional enteritis is a subacute and chronicinflammation that extends through all layers of the bowelwall from the intestinal mucosa. It is characterized byperiods of remissions and exacerbations.• Regional enteritis commonly occurs in adolescents oryoung adults but can appear at any time of life.• It is more common in women, and it occurs frequently inthe older population (between the ages of 50 and 80).• The most common areas are the distal ileum and colon.• Crohn’s disease is seen two times more often in patientswho smoke than in nonsmokers.Inflammatory Bowel Disease
  78. 78. Inflammatory Bowel Disease
  79. 79. Inflammatory Bowel Disease
  80. 80. Inflammatory Bowel Disease
  81. 81. CLINICAL MANIFESTATIONS• Prominent lower right quadrant abdominal pain anddiarrhea unrelieved by defecation.• There is abdominal tenderness and spasm.• Weight loss, malnutrition, and secondary anemia.• Disrupted absorption causes chronic diarrhea andnutritional deficits. The result is a person who is thin andemaciated from inadequate food intake and constantfluid loss.• In some patients, the inflamed intestine may perforate,leading to intra-abdominal and anal abscesses. Feverand leukocytosis occur.Inflammatory Bowel Disease
  82. 82. CLINICAL MANIFESTATIONS• Chronic symptoms include diarrhea, abdominal pain,steatorrhea, anorexia, weight loss, and nutritionaldeficiencies.• The clinical course and symptoms can vary; in somepatients, periods of remission and exacerbation occur,but in others, the disease follows a fulminating course.Inflammatory Bowel DiseaseBarium studies should be withheld if risk ofperforation is high. The increased pressure in theGI tract can increase the risk of perforation.
  83. 83. ASSESSMENT AND DIAGNOSTIC FINDINGS• A proctosigmoidoscopic examination is usuallyperformed initially to determine whether therectosigmoid area is inflamed.• A stool examination is also performed; the result may bepositive for occult blood and steatorrhea.• The most conclusive diagnostic aid for regional enteritisis a barium study of the upper GI tract that shows theclassic “string sign” on an x-ray film of the terminalileum, indicating the constriction of a segment ofintestine. Endoscopy and intestinal biopsy may be usedfor confirmation of the diagnosis.Inflammatory Bowel Disease
  84. 84. ASSESSMENT AND DIAGNOSTIC FINDINGS• A barium enema may show ulcerations (the cobblestoneappearance), fissures, and fistulas.• A CT scan may show bowel wall thickening and fistulatracts.• A complete blood cell count is performed to assesshematocrit and hemoglobin levels and the white bloodcell count. The sedimentation rate is usually elevated.• Albumin and protein levels may be decreased, indicatingmalnutrition.Inflammatory Bowel Disease
  85. 85. COMPLICATIONS• Complications of regional enteritis include intestinalobstruction or stricture formation, perianal disease, fluidand electrolyte imbalances, malnutrition frommalabsorption, and fistula and abscess formation.• The most common type of small bowel fistula thatresults from regional enteritis is the enterocutaneousfistula.• Abscesses can be the result of an internal fistula tractinto an area that results in fluid accumulation andinfection.• Patients with regional enteritis are also at increased riskfor colon cancer.Inflammatory Bowel Disease
  86. 86. ULCERATIVE COLITIS• Ulcerative colitis is a recurrent ulcerative andinflammatory disease of the mucosal and submucosallayers of the colon and rectum.• The incidence of ulcerative colitis is highest inCaucasians and people of Jewish heritage.• The peak incidence is between 30 and 50 years of age.Eventually, 10% to 15% of the patients developcarcinoma of the colon.Inflammatory Bowel DiseaseBloody diarrhea mixed with mucus and often pusis a cardinal sign of ulcerative colitis!
  87. 87. Inflammatory Bowel Disease
  88. 88. CLINICAL MANIFESTATIONS• The predominant symptoms of ulcerative colitis arediarrhea, lower left quadrant abdominal pain, intermittenttenesmus, and rectal bleeding.• The patient may have anorexia, weight loss, fever,vomiting, and dehydration, as well as cramping, thefeeling of an urgent need to defecate, and the passageof 10 to 20 liquid stools each day.• Hypocalcemia and anemia frequently develop.• Rebound tenderness may occur in the right lowerquadrant.Inflammatory Bowel Disease
  89. 89. ASSESSMENT AND DIAGNOSTIC FINDINGS• The patient should be assessed for tachycardia,hypotension, tachypnea, fever, and pallor.• Other assessments include the level of hydration andnutritional status.• The abdomen should be examined for characteristics ofbowel sounds, distention, and tenderness.• The stool is positive for blood, and laboratory test resultsreveal a low hematocrit and hemoglobin concentration inaddition to an elevated white blood cell count, lowalbumin levels, and an electrolyte imbalance.Inflammatory Bowel Disease
  90. 90. ASSESSMENT AND DIAGNOSTIC FINDINGS• Abdominal x-ray studies are useful for determining thecause of symptoms.• Sigmoidoscopy or colonoscopy and barium enema arevaluable in distinguishing this condition from otherdiseases of the colon with similar symptoms.• Endoscopy may reveal friable, inflamed mucosa withexudate and ulcerations.• CT scanning, magnetic resonance imaging, andultrasound can identify abscesses and perirectalinvolvement.Inflammatory Bowel Disease
  91. 91. COMPLICATIONS• Complications of ulcerative colitis include toxicmegacolon, perforation, and bleeding as a result ofulceration, vascular engorgement, and highly vasculargranulation tissue.• Patients with IBD also have a significantly increased riskof osteoporotic fractures due to decreased bone mineraldensity. Corticosteroid therapy may also contribute to thediminished bone mass.Inflammatory Bowel Disease
  92. 92. MEDICAL MANAGEMENTNUTRITIONAL THERAPY• Oral fluids and a low-residue, high-protein, high-caloriediet with supplemental vitamin therapy and ironreplacement are prescribed to meet nutritional needs,reduce inflammation, and control pain and diarrhea.• Fluid and electrolyte imbalances from dehydrationcaused by diarrhea are corrected by intravenous therapyas necessary.• Any foods that exacerbate diarrhea are avoided. Coldfoods and smoking are avoided.Inflammatory Bowel Disease
  93. 93. MEDICAL MANAGEMENTPHARMACOLOGIC THERAPY• Sedatives and antidiarrheal and antiperistalticmedications are used to minimize peristalsis to rest theinflamed bowel.• Aminosalicylate formulations such as sulfasalazine(Azulfidine) are often effective for mild or moderateinflammation and are used to prevent or reducerecurrences in long-term maintenance regimens.• Antibiotics are used for secondary infections, particularlyfor purulent complications such as abscesses,perforation, and peritonitis.Inflammatory Bowel Disease
  94. 94. MEDICAL MANAGEMENTPHARMACOLOGIC THERAPY• Corticosteroids are used to treat severe and fulminantdisease.• Immunomodulators (eg, azathioprene [Imuran], 6-mercaptopurine, methotrexate, cyclosporin) have beenused to alter the immune response.Inflammatory Bowel Disease
  95. 95. SURGICAL MANAGEMENT• The procedure of choice is a total colectomy andileostomy.• A newer surgical procedure developed for patients withsevere regional enteritis is intestinal transplant.• Indications for surgery include lack of improvement andcontinued deterioration, profuse bleeding, perforation,stricture formation, and cancer. Surgical excision usuallyimproves quality of life.Inflammatory Bowel Disease
  96. 96. TOTAL COLECTOMY WITH ILEOSTOMY• An ileostomy, the surgical creation of an opening into theileum or small intestine, is commonly performed after atotal colectomy.• It allows for drainage of fecal matter (ie, effluent) fromthe ileum to the outside of the body.• The drainage is very mushy and occurs at frequentintervals.Inflammatory Bowel Disease
  97. 97. Inflammatory Bowel DiseaseTOTAL COLECTOMY WITH CONTINENT ILEOSTOMY• Another procedure involves the removal of the entirecolon and creation of the continent ileal reservoir.• This procedure eliminates the need for an externalfecal collection bag.• GI effluent can accumulate in the pouch for severalhours and then be removed by means of a catheterinserted through the nipple valve.
  98. 98. Inflammatory Bowel DiseaseTOTAL COLECTOMY WITH ILEOANAL ANASTOMOSIS• It establishes an ileal reservoir, and anal sphinctercontrol of elimination is retained.• The procedure involves connecting a portion of theileum to the anus in conjunction with removal of thecolon and the rectal mucosa.• A temporary diverting loop ileostomy is constructed atthe time of surgery and closed about 3 months later.
  99. 99. Inflammatory Bowel Disease
  100. 100. MANAGING SKIN AND STOMA CARE• Usually, the ileostomy stoma is about 2.5 cm (1 in) long,• which makes it convenient for the attachment of anappliance.• Peristomal skin integrity may be compromised byseveral factors, such as an allergic reaction to theostomy appliance, skin barrier, or paste; chemicalirritation from the effluent; mechanical injury from theremoval of the appliance; and possible infection.• If irritation and yeast growth occur, nystatin powder(Mycostatin) is dusted lightly on the peristomal skin.Inflammatory Bowel Disease
  101. 101. CHANGING AN APPLIANCE• The usual wearing time is 5 to 7 days.• The appliance is emptied every 4 to 6 hours or at thesame time the patient empties the bladder.• Bismuth subcarbonate tablets, which may be prescribedand taken by mouth three or four times each day, areeffective in reducing odor. A stool thickener, such asdiphenoxylate (Lomotil), can also be prescribed andtaken orally to assist in odor control.Inflammatory Bowel Disease
  102. 102. IRRIGATING A CONTINENT ILEOSTOMY• A catheter is inserted into the reservoir to drain the fluid.The length of time between drainage periods isgradually increased until the reservoir needs to bedrained only every 4 to 6 hours and irrigated once eachday.• A pouch is not necessary; instead, most patients wear asmall dressing over the opening.• When the fecal discharge is thick, water can be injectedthrough the catheter to loosen and soften it.Inflammatory Bowel Disease
  103. 103. MANAGING DIETARY AND FLUID NEEDS• A low-residue diet is followed for the first 6 to 8 weeks.Strained fruits and vegetables are given.• If the fecal discharge is too watery, fibrous foods (eg,whole-grain cereals, fresh fruit skins, beans, corn, nuts)are restricted.• If the effluent is excessively dry, salt intake is increased.• Increased intake of water or fluid does not increase theeffluent, because excess water is excreted in the urine.Inflammatory Bowel Disease
  104. 104. Intestinal obstruction exists when blockage prevents thenormal flow of intestinal contents through the intestinaltract.Two types of processes can impede this flow.• Mechanical obstruction: An intraluminal obstruction ora mural obstruction from pressure on the intestinal wallsoccurs.Examples are intussusception, polypoid tumors andneoplasms, stenosis, strictures, adhesions, hernias, andabscesses.Intestinal Obstruction
  105. 105. • Functional obstruction: The intestinal musculaturecannot propel the contents along the bowel.Examples are amyloidosis, muscular dystrophy,endocrine disorders such as diabetes mellitus, orneurologic disorders such as Parkinson’s disease. Theblockage also can be temporary and the result of themanipulation of the bowel during surgeIntestinal Obstruction
  106. 106. MECHANICAL CAUSES OF INTESTINAL OBSTRUCTIONIntestinal Obstruction• AdhesionsLoops of intestine become adherent to areas that healslowly or scar after abdominal surgery.• IntussusceptionOne part of the intestine slips into another part locatedbelow it (like a telescope shortening).• VolvulusBowel twists and turns on itself.
  107. 107. MECHANICAL CAUSES OF INTESTINAL OBSTRUCTIONIntestinal Obstruction• HerniaProtrusion of intestine through a weakened area in theabdominal muscle or wall.• TumorA tumor that exists within the wall of the intestineextends into the intestinal lumen, or a tumor outside theintestine causes pressure on the wall of the intestine.
  108. 108. Intestinal Obstruction
  109. 109. Intestinal Obstruction
  110. 110. Intestinal ObstructionCLINICAL MANIFESTATIONS• The initial symptom is usually crampy pain that iswavelike and colicky.• The patient may pass blood and mucus, but no fecalmatter and no flatus.• Vomiting occurs.• If the obstruction is complete, the peristaltic wavesinitially become extremely vigorous and eventuallyassume a reverse direction, with the intestinal contentspropelled toward the mouth instead of toward therectum.
  111. 111. Intestinal ObstructionCLINICAL MANIFESTATIONS• If the obstruction is in the ileum, fecal vomiting takesplace.• The unmistakable signs of dehydration become evident:intense thirst, drowsiness, generalized malaise, aching,and a parched tongue and mucous membranes.• The abdomen becomes distended. The lower theobstruction is in the GI tract, the more marked theabdominal distention.• If the obstruction continues uncorrected, hypovolemicshock occurs from dehydration and loss of plasmavolume.
  112. 112. Intestinal ObstructionASSESSMENT AND DIAGNOSTIC FINDINGS• Abdominal x-ray studies show abnormal quantities ofgas, fluid, or both in the bowel.• Laboratory studies (ie, electrolyte studies and acomplete blood cell count) reveal a picture ofdehydration, loss of plasma volume, and possibleinfection.
  113. 113. Intestinal ObstructionMEDICAL MANAGEMENT• Decompression of the bowel through a nasogastric orsmall bowel tube is successful in most cases.• Before surgery, intravenous therapy is necessary toreplace the depleted water, sodium, chloride, andpotassium.• The surgical treatment of intestinal obstruction dependslargely on the cause of the obstruction.• The complexity of the surgical procedure for intestinalobstruction depends on the duration of the obstructionand the condition of the intestine.
  114. 114. Intestinal ObstructionNURSING MANAGEMENT• Nursing management of the nonsurgical patient with asmall bowel obstruction includes maintaining thefunction of the nasogastric tube, assessing andmeasuring the nasogastric output, assessing for fluidand electrolyte imbalance, monitoring nutritional status,and assessing improvement (eg, return of normal• bowel sounds, decreased abdominal distention,subjective improvement in abdominal pain andtenderness, passage of flatus or stool).• The nurse reports discrepancies in intake and output,worsening of pain or abdominal distention, andincreased nasogastric output.
  115. 115. Intestinal ObstructionLARGE BOWEL OBSTRUCTION• Large bowel obstruction results in an accumulation ofintestinal contents, fluid, and gas proximal to theobstruction.• Obstruction in the large bowel can lead to severedistention and perforation unless some gas and fluid canflow back through the ileal valve.• Large bowel obstruction, even if complete, may beundramatic if the blood supply to the colon is notdisturbed.
  116. 116. Intestinal ObstructionCLINICAL MANIFESTATIONS• In patients with obstruction in the sigmoid colon or therectum, constipation may be the only symptom for days.• Eventually, the abdomen becomes markedly distended,loops of large bowel become visibly outlined through theabdominal wall, and the patient has crampy lowerabdominal pain.• Finally, fecal vomiting develops.• Symptoms of shock may occur.
  117. 117. Intestinal ObstructionASSESSMENT AND DIAGNOSTIC FINDINGS• Diagnosis is based on symptoms and on x-ray studies.• Abdominal x-ray studies (flat and upright) show adistended colon.• Barium studies are contraindicated.
  118. 118. Intestinal ObstructionMEDICAL MANAGEMENT• A colonoscopy may be performed to untwist anddecompress the bowel.• A cecostomy, in which a surgical opening is made into thececum, may be performed for patients who are poorsurgical risks and urgently need relief from the obstruction.• A rectal tube may be used to decompress an area that islower in the bowel.• The usual treatment, however, is surgical resection toremove the obstructing lesion.• A temporary or permanent colostomy may be necessary.An ileoanal anastomosis may be performed if it isnecessary to remove the entire large colon.
  119. 119. Intestinal ObstructionNURSING MANAGEMENT• The nurse’s role is to monitor the patient for symptomsthat indicate that the intestinal obstruction is worseningand to provide emotional support and comfort.• The nurse administers intravenous fluids and electrolytesas prescribed.• After surgery, general abdominal wound care and routinepostoperative nursing care are provided.
  120. 120. Colorectal CancerCOLORECTAL CANCER• Tumors of the colon and rectum are relatively common;the colorectal area is now the third most common site ofnew cancer cases and deaths.• The incidence increases with age (the incidence ishighest for people older than 85 years of age) and ishigher for people with a family history of colon cancerand those with IBD or polyps.• The exact cause of colon and rectal cancer is stillunknown, but risk factors have been identified.
  121. 121. Colorectal Cancer
  122. 122. Colorectal Cancer
  123. 123. Colorectal CancerCLINICAL MANIFESTATIONS• The symptoms are greatly determined by the location ofthe cancer, the stage of the disease, and the function ofthe intestinal segment in which it is located.• The most common presenting symptom is a change inbowel habits.• The passage of blood in the stools is the second mostcommon symptom.• Symptoms may also include unexplained anemia,anorexia, weight loss, and fatigue.• The symptoms most commonly associated with right-sided lesions are dull abdominal pain and melena (ie,black, tarry stools).
  124. 124. Colorectal CancerCLINICAL MANIFESTATIONS• The symptoms most commonly associated with left-sided lesions are those associated with obstruction (ie,abdominal pain and cramping, narrowing stools,constipation, and distention), as well as bright red bloodin the stool.• Symptoms associated with rectal lesions are tenesmus,rectal pain, the feeling of incomplete evacuation after abowel movement, alternating constipation and diarrhea,and bloody stool.
  125. 125. Colorectal CancerASSESSMENT AND DIAGNOSTIC FINDINGS• Along with an abdominal and rectal examination, themost important diagnostic procedures for cancer of thecolon are fecal occult blood testing, barium enema,proctosigmoidoscopy, and colonoscopy.• As many as 60% of colorectal cancer cases can beidentified by sigmoidoscopy with biopsy or cytologysmears.• Carcinoembryonic antigen (CEA) studies may also beperformed.
  126. 126. Colorectal CancerSTAGING OF COLORECTAL CANCER:DUKES’ CLASSIFICATION–MODIFIED STAGING SYSTEMClass A:Tumor limited to muscular mucosa and submucosaClass B1:Tumor extends into mucosaClass B2 :Tumor extends through entire bowel wall into serosa orpericolic fat, no nodal involvement
  127. 127. Colorectal CancerSTAGING OF COLORECTAL CANCER:DUKES’ CLASSIFICATION–MODIFIED STAGING SYSTEMClass C1:Positive nodes, tumor is limited to bowel wallClass C2 :Positive nodes, tumor extends through entire bowel wallClass D:Advanced and metastasis to liver, lung, or bone
  128. 128. Colorectal CancerSTAGING OF COLORECTAL CANCER:Another staging system, the TNM (tumor, nodalinvolvement, metastasis) classification, may be used todescribe the anatomic extent of the primary tumor,depending on• Size, invasion depth and surface spread• Extent of nodal involvement• Presence or absence of metastasis
  129. 129. Colorectal CancerCOMPLICATIONS• Tumor growth may cause partial or complete bowelobstruction.• Extension of the tumor and ulceration into thesurrounding blood vessels results in hemorrhage.• Perforation, abscess formation, peritonitis, sepsis, andshock may occur.
  130. 130. Colorectal CancerMEDICAL MANAGEMENT• The patient with symptoms of intestinal obstruction istreated with intravenous fluids and nasogastric suction.• If there has been significant bleeding, blood componenttherapy may be required.• Treatment for colorectal cancer depends on the stage ofthe disease and consists of surgery to remove thetumor, supportive therapy, and adjuvant therapy
  131. 131. Colorectal CancerSURGICAL MANAGEMENT• Surgery is the primary treatment for most colon and rectalcancers. It may be curative or palliative.• Cancers limited to one site can be removed through thecolonoscope.• Laparoscopic colotomy with polypectomy minimizes theextent of surgery needed in some cases.• Bowel resection is indicated for most class A lesions and allclass B and C lesions.• Surgery is sometimes recommended for class D coloncancer, but the goal of surgery in this instance is palliative;if the tumor has spread and involves surrounding vitalstructures, it is considered nonresectable.
  132. 132. Colorectal CancerSURGICAL MANAGEMENTSurgical procedures include the following:• Segmental resection with anastomosis (ie, removal ofthe tumor and portions of the bowel on either side of thegrowth, as well as the blood vessels and lymphatic nodes).• Abdominoperineal resection with permanent sigmoidcolostomy (ie, removal of the tumor and a portion of thesigmoid and all of the rectum and anal sphincter).• Temporary colostomy followed by segmental resection andanastomosis and subsequent reanastomosis of thecolostomy, allowing initial bowel decompression and bowelpreparation before resection
  133. 133. Colorectal CancerSURGICAL MANAGEMENT• Permanent colostomy or ileostomy for palliation ofunresectable obstructing lesions• Construction of a coloanal reservoir called a colonic Jpouch is performed in two steps. A temporary loopileostomy is constructed to divert intestinal flow, and thenewly constructed J pouch is reattached to the analstump. About 3 months after the initial stage, theileostomy is reversed, and intestinal continuity isrestored. The anal sphincter and therefore continenceare preserved.
  134. 134. Colostomy• A colostomy is the surgical creation of an opening (ie,stoma) into the colon.• It can be created as a temporary or permanent fecaldiversion.• It allows the drainage or evacuation of colon contents tothe outside of the body.• The consistency of the drainage is related to theplacement of the colostomy, which is dictated by thelocation of the tumor and the extent of invasion intosurrounding tissues.
  135. 135. Colostomy• A colostomy is the surgical creation of an opening (ie,stoma) into the colon.• It can be created as a temporary or permanent fecaldiversion.• It allows the drainage or evacuation of colon contents tothe outside of the body.• The consistency of the drainage is related to theplacement of the colostomy, which is dictated by thelocation of the tumor and the extent of invasion intosurrounding tissues.
  136. 136. Intestinal Obstruction
  137. 137. Intestinal Obstruction
  138. 138. Intestinal Obstruction
  139. 139. Intestinal Obstruction
  140. 140. Intestinal Obstruction
  141. 141. ColostomyREMOVING AND APPLYING THE COLOSTOMY APPLIANCE• To remove the appliance, the patient assumes acomfortable sitting or standing position and gentlypushes the skin down from the faceplate while pullingthe pouch up and away from the stoma.• The nurse advises the patient to protect the peristomalskin by then washing the area gently with a moist, softcloth and a mild soap.• While the skin is being cleansed, a gauze dressing cancover the stoma to absorb excess drainage.• After cleansing, the patient pats the skin completely drywith a gauze pad, taking care not to rub the area.
  142. 142. ColostomyREMOVING AND APPLYING THE COLOSTOMY APPLIANCE• The patient can lightly dust nystatin (Mycostatin) powderon the peristomal skin if irritation or yeast growth ispresent.• Smoothly applying the drainage appliance for a securefit requires practice and a well-fitting appliance.• Patients can choose from a wide variety of appliances,depending on their individual
  143. 143. ColostomyIRRIGATING THE COLOSTOMY• The purpose of irrigating a colostomy is to empty thecolon of gas, mucus, and feces so that the patient cango about social and business activities without fear offecal drainage.• By irrigating the stoma at a regular time, there is lessgas and retention of the irrigant.
  144. 144. ColostomySUPPORTING A POSITIVE BODY IMAGE• The patient is encouraged to verbalize feelings andconcerns about altered body image and to discuss thesurgery and the stoma (if one was created).• A supportive environment and a supportive attitude onthe nurse’s part are crucial in promoting the patient’sadaptation to the changes brought about by the surgery.• If applicable, the patient must learn colostomy care andbegin to plan for incorporating stoma care into daily life.• The nurse helps the patient overcome aversion to thestoma or fear
  145. 145. ColostomyDISCUSSING SEXUALITY ISSUES• The nurse encourages the patient to discuss feelingsabout sexuality and sexual function. Some patients mayview the surgery as mutilating and a threat to theirsexuality; some fear impotence. Others may expressworry about odor or leakage from the pouch duringsexual activity.• Alternative sexual positions are recommended, as wellas alternative methods of stimulation to satisfy sexualdrives.
  146. 146. PolypsPOLYPS OF THE COLON AND RECTUM• A polyp is a mass of tissue that protrudes into the lumenof the bowel. Polyps can occur anywhere in theintestinal tract and rectum.• They can be classified as neoplastic (ie, adenomas andcarcinomas) or non-neoplastic (ie, mucosal andhyperplastic).
  147. 147. PolypsPOLYPS OF THE COLON AND RECTUM• Clinical manifestations depend on the size of the polypand the amount of pressure it exerts on intestinal tissue.• The most common symptom is rectal bleeding.• Lower abdominal pain may also occur.• If the polyp is large enough, symptoms of obstructionoccur.• The diagnosis is based on history and digital rectalexamination, barium enema studies, sigmoidoscopy, orcolonoscopy.
  148. 148. PolypsPOLYPS OF THE COLON AND RECTUM• After a polyp is identified, it should be removed.• There are several methods: colonoscopy with the use ofspecial equipment (ie, biopsy forceps and snares),laparoscopy, or colonoscopic excision with laparoscopicvisualization.• Microscopic examination of the polyp then identifies thetype of polyp and indicates what further surgery isrequired.
  149. 149. Diseases of the AnorectumANORECTAL ABSCESS• An anorectal abscess is caused by obstruction of ananal gland, resulting in retrograde infection. Many ofthese abscesses result infistulas.• An abscess may occur in a variety of spaces in andaround the rectum. It often contains a quantity of foul-smelling pus and is painful. If the abscess is superficial,swelling, redness, and tenderness are observed.• A deeper abscess may result in toxic symptoms, lowerabdominal pain, and fever.• Palliative therapy consists of sitz baths and analgesics.However,
  150. 150. Diseases of the AnorectumANORECTAL ABSCESS• Prompt surgical treatment to incise and drain theabscess is the treatment of choice.• When a deeper infection exists with the possibility of afistula, the fistulous tract must be excised.• The wound may be packed with gauze and allowed toheal by granulation.
  151. 151. Diseases of the AnorectumANAL FISTULA• An anal fistula is a tiny, tubular, fibrous tract that extendsinto the anal canal from an opening located beside theanus.• Fistulas usually result from an infection. They may alsodevelop from trauma, fissures, or regional enteritis. Pusor stool may leak constantly from the cutaneousopening.• Other symptoms may be the passage of flatus or fecesfrom the vagina or bladder, depending on the fistulatract.
  152. 152. Anal Fistula
  153. 153. Diseases of the AnorectumANAL FISTULA• A fistulectomy (ie, excision of the fistulous tract) is therecommended surgical procedure.• The lower bowel is evacuated thoroughly with severalprescribed enemas.• During surgery, the sinus tract is identified by inserting aprobe into it or by injecting the tract with methylene bluesolution.• The fistula is dissected out or laid open by an incisionfrom its rectal opening to its outlet.• The wound is packed with gauze.
  154. 154. Diseases of the AnorectumANAL FISSURE• An anal fissure is a longitudinal tear or ulceration in thelining of the anal canal.• Fissures are usually caused by the trauma of passing alarge, firm stool or from persistent tightening of the analcanal because of stress and anxiety. Other causesinclude childbirth, trauma, and overuse of laxatives.• Extremely painful defecation, burning, and bleedingcharacterize fissures.• Most of these fissures heal if treated by conservativemeasures, which include stool softeners and bulkagents, an increase in water intake, sitz baths, andemollient suppositories.
  155. 155. Anal Fissure
  156. 156. Diseases of the AnorectumANAL FISSURE• A suppository combining an anesthetic with acorticosteroid helps relieve the discomfort.• If fissures do not respond to conservative treatment,surgery is indicated. The procedure considered by mostsurgeons to be the procedure of choice is the lateralinternal sphincterotomy with excision of the fissure.
  157. 157. Diseases of the AnorectumHEMORRHOIDS• Hemorrhoids are dilated portions of veins in the analcanal.• By the age of 50, about 50% of people havehemorrhoids to some extent. Shearing of the mucosaduring defecation results in the sliding of the structuresin the wall of the anal canal, including the hemorrhoidaland vascular tissues.• Hemorrhoids are classified as one of two types. Thoseabove the internal sphincter are called internalhemorrhoids, and those appearing outside the externalsphincter are called external hemorrhoids.
  158. 158. Hemorrhoids
  159. 159. Diseases of the AnorectumHEMORRHOIDS• Hemorrhoids cause itching and pain and are the mostcommon cause of bright red bleeding with defecation.• External hemorrhoids are associated with severe painfrom the inflammation and edema caused by thrombosis(ie, clotting of blood within the hemorrhoid).• Internal hemorrhoids are not usually painful until theybleed or prolapse when they become enlarged.• Hemorrhoid symptoms and discomfort can be relievedby good personal hygiene and by avoiding excessivestraining during defecation.
  160. 160. Diseases of the AnorectumHEMORRHOIDS• A high-residue diet that contains fruit and bran alongwith an increased fluid intake may be all the treatmentthat is necessary to promote the passage of soft, bulkystools to prevent straining.• If this treatment is not successful, the addition ofhydrophilic bulk-forming agents such as psyllium andmucilloid may help.• Warm compresses, sitz baths, analgesic ointments andsuppositories, astringents, and bed rest allow theengorgement to subside.
  161. 161. Diseases of the AnorectumHEMORRHOIDS• Infrared photocoagulation, bipolar diathermy, and lasertherapy are newer techniques that are used to affix themucosa to the underlying muscle.• Injecting sclerosing solutions is also effective for small,bleeding hemorrhoids.• A conservative surgical treatment of internalhemorrhoids is the rubber-band ligation procedure.• The Nd:YAG laser is useful in excising hemorrhoids,particularly external hemorrhoidal tags. The treatment isquick and relatively painless.
  162. 162. Diseases of the AnorectumHEMORRHOIDS• Hemorrhoidectomy, or surgical excision, can beperformed to remove all the redundant tissue involved inthe process.• After the operative procedures are completed, a smalltube may be inserted through the sphincter to permit theescape of flatus and blood; pieces of Gelfoam or Oxycelgauze may be placed over the anal wounds.
  163. 163. ST Anorectal Diseases• Proctitis involves the rectum. It is commonly associatedwith recent anal-receptive intercourse with an infectedpartner. Symptoms include a mucopurulent discharge orbleeding, pain in the area, and diarrhea. The pathogensmost frequently involved are Neisseria gonorrheae(53%), Chlamydia (20%), herpes simplex virus (18%),and Treponema pallidium (9%)• Enteritis involves more of the descending colon, andsymptoms include watery, bloody diarrhea; abdominalpain; and weight loss. The most common pathogenscausing enteritis are E. histolytica, Giardia lamblia,Shigella, and Campylobacter.
  164. 164. ST Anorectal Diseases• Sigmoidoscopy is performed to identify portions of theanorectum involved. Samples are taken with rectalswabs, and cultures are obtained to identify thepathogens involved.• The treatment of choice for bacterial infections isantibiotics (ie, cefixime, doxycycline, and penicillin).Acyclovir is given to those with viral infections.• Infections from E. histolytica and G. lamblia are treatedwith antiamebic therapy (ie, metronidazole).Ciprofloxacin is an effective treatment for Shigella.Antibiotics of choice for Campylobacter infection areerythromycin and ciprofloxacin.
  165. 165. Multiple Choice1. A 40-year-old male client has been hospitalized withpeptic ulcer disease. He is being treated with a his-tamine receptor antagonist (cimetidine), antacids, anddiet. Nurse Jackie doing the discharge planning willteach him that the action of cimetidine is toa. Protect the ulcer surface.b. Reduce gastric acid output.c. Inhibit vagus nerve stimulation.d. Inhibit the production of hydrochloric acid (HCl).
  166. 166. Multiple Choice2. Discharge planning for a client with a partial colectomywill include which one of the following dietaryprinciples?a. High fiber, no spices.b. High residue, force fluids.c. Regular, no dairy products.d. Low residue, no dairy products.
  167. 167. Multiple Choice3. Following abdominal surgery, a client complaining of"gas pains" will have a rectal tube inserted. NurseJackie should know that the client should bepositioned on hisa. Right side, semi-Fowlers.b. Left side, semi-Fowlers.c. Left side, Sims.d. Left side, recumbent.
  168. 168. Multiple Choice4. A client is scheduled for colostomy surgery. Anappropriate preoperative diet will includea. Broiled chicken, baked potato, and wheat bread.b. Steak, mashed potatoes, raw carrots, and celery.c. Broiled fish, rice, squash, and tea.d. Ground hamburger, rice, and salad.
  169. 169. Multiple Choice5. A client who has just returned home following ileostomysurgery will need a diet that is supplemented witha. Vitamin B12.b. Fiber.c. Sodium.d. Potassium.
  170. 170. Multiple Choice6. Assessing the client following abdominal surgery,Nurse Jackie observes pinkish fluid and a loop ofbowel through an opening in the incision. The firstnursing action is toa. Cover the protruding bowel with a moist, sterile,normal saline dressing.b. Notify the operating room for wound closure.c. Notify the physician.d. Apply butterfly tapes to the incision area.
  171. 171. Multiple Choice7. A female client complains of gnawing midepigastricpain for a few hours after meals. At times, when thepain is severe, vomiting occurs. Specific tests areindicated to rule outa. Chronic gastritis.b. Peptic ulcer disease.c. Pylorospasmd. Cancer of the stomach.
  172. 172. Multiple Choice8. Nurse Jackie will know that the client understandspresurgical instructions for hemorrhoid surgery if hisdiet isa. Low roughage.b. High fiber.c. Low fiber.d. High carbohydrate.
  173. 173. Multiple Choice9. When administering a one-time dose of Valium (abenzodiazepine drug) to a client, Nurse Jackie needsto inform the client thata. Valium directly affects the blood pressure as avasoconstrictor.b. There are no important side effects to considerbecause it is a one-time dose.c. Valium should never be mixed with foods containingtyramine.d. Valium has sedative properties.
  174. 174. Multiple Choice10. Nurse Jackie asks a client to list the snacks he likesthat are allowed on his low-fat, low-sodium, low-cholesterol diet. He realizes that further dietaryteaching is necessary when one of his choices isa. An apple.b. Applesauce.c. Buttermilk.d. A jam sandwich.
  175. 175. Multiple Choice11. Evaluating the effectiveness of preoperative teachingbefore colostomy surgery, Nurse Jackie expects thatthe client will be able toa. Describe how the procedure will be done.b. Explain the function of the colostomy.c. Exhibit acceptance of the surgery.d. Apply the colostomy bag correctly.
  176. 176. Multiple Choice12. Nurse Jackie is admitting a client with Crohnsdisease who is scheduled for intestinal surgery.Which surgical procedure would the nurse anticipatefor the treatment of this condition?a.Ileostomy with total colectomy.b.Intestinal resection with end-to-end anastomosis.c.Colonoscopy with biopsy and polypectomy.d.Sigmoid colostomy with mucous fistula.
  177. 177. Multiple Choice13. A 53-year-old client with Crohns disease is placed onTPN. The fluid in the present TPN bottle should beinfused by 8 A.M. At 7 A.M. nurse Jackie observesthat it is empty and another TPN bottle has not yetarrived on the unit. The nursing action is to attach abottle ofa. D10 and water.b. D45 and water.c. D25 and water.d. D5 and water.
  178. 178. Multiple Choice14. Nurse Jackie is teaching a client with a newcolostomy how to apply an appliance to a colostomy.How much skin should remain exposed between thestoma and the ring of the appliance?a.1/2 inch.b.1 inch.c. 1/8 inch.d.3/4 inch.
  179. 179. Multiple Choice15. Hemorrhage is a major complication following oralsurgery and radical neck dissection. If this conditionoccurs, the most immediate nursing interventionwould be toa. Immediately put the client in high-Fowlersposition.b. Treat the client for shock.c. Put pressure over the common carotid and jugularvessels in the neck.d. Notify the surgeon immediately.
  180. 180. Multiple Choice16. Which one of the statements is most accurate about thedrug cimetidine (Tagamet) and should be discussedwith clients who take the medication?a. Tagamet should be taken on an empty stomach forbetter absorption.b. Tagamet should be used cautiously with clients onCoumadin because it could inhibit the absorption ofthe drug.c. Tagamet is usually prescribed for long-termprevention of gastric ulcers.d. Tagamet should be taken with an antacid to decreaseGI distress, a common occurrence with the drug.
  181. 181. Multiple Choice17. Nurse Jackie’s diet instructions for a client with acolostomy will bea. Low in fiber with a large amount of fluids.b. High in fiber with large amounts of fluids andsupplemental vitamin K.c. According to his own individual needs and similarto his preoperative diet.d. Elimination of milk products.
  182. 182. Multiple Choice18. Nurse Jackie is giving health teaching regardingcolorectal cancer. Which is identified as a potentialrisk?a. Chronic constipationb. Long term laxative usec. History of smokingd. History of inflammatory bowel disease
  183. 183. Multiple Choice19. When preparing a client for a scheduled colonoscopy,which of the following would nurse Jackie includea. Inserting a nasogastric tube 12 hours before theprocedureb. Cleansing the bowel with laxatives or enemasc. Administering an antibiotic to decrease the risk ofinfection.d. Spraying a local anesthetic into the clients throatto calm the gag reflex.
  184. 184. Multiple Choice20. Which of the following nursing interventions is mostappropriate when caring for a client who has an acutecase of stomatitis?a. Using a soft toothbrush to provide oral hygiene.b. Rinsing mouth with commercial mouthwash beforeand after each meal.c. Cleansing gums and oral mucosa with lemon-glycerin swabs every shift.d. Keeping dentures in place to decreasedevelopment of edema.

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